Journal of Chiropractic Medicine (2015) 14, 68–76

www.journalchiromed.com

Topics in Sports Medicine

Laboratory Tests Ordered By a Chiropractic

Sports Physician on Elite Athletes Over a 1-Year
Period
Dustin C. Nabhan DC, DACBSP, CSCS a,⁎, William J. Moreau DC, DACBSP, CSCS b ,
Chad Barylski DC, DACBSP, MSN, NP-C c
a
Associate Director, Clinical Research and Multidisciplinary Care United State Olympic Committee,
Colorado Springs, Colorado
b
Managing Director of Sports Medicine, United States Olympic Committee, Colorado Springs, Colorado
c
Nurse Practitioner, Annadel Medical Group Family Medicine/UCSF Medical Center Department of
Orthopedics/Neurosurgery, Santa Rosa, California

Received 16 December 2012; received in revised form 12 April 2015; accepted 15 April 2015

Key indexing terms:

Abstract
Chiropractic;
Objective: The purpose of this study is to describe and discuss laboratory tests ordered on
Sports medicine;
elite athletes in an interdisciplinary sports medicine clinic by a doctor of chiropractic over 1
Clinical laboratory
calendar year.
techniques;
Methods: A retrospective review of laboratory tests ordered during routine clinical practice as
Diagnosis
standard screening and diagnostic tests from November 1, 2009, to November 1, 2010 was
performed. Data were collected during clinical encounters at one sports medicine clinic and
entered into a database for analysis. Descriptive and frequency statistics were used to describe
the tests ordered and the frequency of abnormal findings.
Results: Five hundred and thirty-nine studies were ordered for diagnostic and routine
screenings on 137 athlete patients (86 males, 51 females), representing 49 types of tests.
Sample sources included blood, urine, skin lesions, and fecal matter. The most commonly
ordered tests were complete blood count, comprehensive metabolic panel, serum ferritin,
creatine kinase, serum iron and total iron binding capacity, total cortisol, thyroid stimulating
hormone, and lipid panels. There were 217 studies (40%) flagged as abnormal by the
reporting laboratory.
Conclusion: : This report provides greater insight into the diverse array of laboratory studies
ordered over a 1-year period for diagnosis and screening of elite athletes. A high percentage of the
results were flagged as abnormal by the laboratory. These findings show that the unique physiology
of the elite athlete must be considered when interpreting laboratory findings in this population.
© 2015 National University of Health Sciences. Open access under CC BY-NC-ND license.

⁎ Corresponding author at: 1 Olympic Plaza Colorado Springs CO 80919. Tel.: + 1 928 580 3642.
E-mail address: nabhandc@gmail.com (D. C. Nabhan).

http://dx.doi.org/10.1016/j.jcm.2015.04.001
1556-3707 © 2015 National University of Health Sciences. Open access under CC BY-NC-ND license.
Laboratory Tests
Introduction
Quality health care requires a thorough assessment
of each patient’s health status, including a detailed
history and physical examination, as well as appro-
priate laboratory and diagnostic testing. It is accepted
that the judicious use of laboratory tests coupled with
thoughtful interpretation of the results of these tests is
an important tool in clinical decision-making and
patient management. Laboratory tests are commonly
used in periodic evaluation of the healthy athlete. 1–7
Owing to the metabolic stress of training for sport,
laboratory results in elite athletes may differ from the
general population. 1 The sports medicine clinician
must be astute as to how training affects laboratory
results and the clinical relevance of abnormal
findings. This has been described in limited detail in
previous manuscripts; however, a thorough descrip-
tion of the tests commonly ordered and the frequency
of findings outside of the reference range has not been
published. 1–3 Publication of test results in athletic
populations may help clinicians better understand
what is “normal” in this special population and the
clinical significance of abnormal findings.
Practice patterns regarding the use of diagnostic
laboratory tests by doctors of chiropractic have not
been thoroughly described in medical literature, and no
studies on this topic have been published in regards to
chiropractic management of the athletic patient.
Chiropractors are trained in laboratory testing and
interpretation during their curriculum. Commonly
ordered tests in chiropractic practice include complete
blood counts (CBC), comprehensive metabolic panels
(CMP), urinalysis, erythrocyte sedimentation rate, C-
reactive protein, random and fasting serum glucose, he-
moglobin A1c, serum lipid panels, vitamin B12, vitamin D,
fecal occult blood tests, and allergen testing. 8 It has been
reported that chiropractors order diagnostic laboratory
tests on a yearly basis and review laboratory data and
interpret the results on a monthly basis. 9 However,
chiropractors have been reported to see a very low
importance in regard to the collection and processing
of laboratory tests, with importance of these skills
being scored as 0.6 out of 20 (20 being the highest
value). 9
The purpose of this study was to describe what tests
were commonly ordered by 1 doctor of chiropractic in
a sports medicine setting during 1 calendar year, to
describe common abnormal findings in this popu-
lation, and to discuss the clinical significance of
these findings.
69
Methods
This retrospective observational study represents the
analyses of 1 calendar year of laboratory data
(November 1, 2009-2010) on all laboratory studies
ordered by a sports medicine certified chiropractic
physician in one clinic (United States Olympic
Training Center, Colorado Springs, CO) with a patient
population of elite athletes. Athletes with access to this
clinic are involved in a wide range of sports divided
into categories such as power, endurance, combat, and
acrobat sport. The population studied was variable in
regard to age, gender, and sport; however, only elite
athletes have access to the clinic facilities and were
therefore the target of this study. This clinic serves a
resident population of 175 athletes and may serve an
additional 200 to 300 athletes at any given time on a on
a temporary basis throughout the calendar year, with an
estimated 10,000 patient visits annually.
During the 1-year period observed, studies were
ordered by the attending chiropractic physician for
diagnostic testing during injury or illness, during routine
physical examinations as a screening measures during
periodic health examination, or as part of multidisciplin-
ary management with sports performance or medicine
consultants such as sport dietitians or exercise physiolo-
gists for performance purposes, and never as a means of
screening for performance enhancing drugs.
All tests were ordered by a single practitioner and
collected by the physician or clinic staff and sent to a
local laboratory for analysis. A database of all test
results ordered by the lead clinician was provided by
the contracted external laboratory (Quest Diagnostics,
Denver, CO) at the end of the calendar year and then
stripped of all patient identifiers before analysis. No chart
reviews were performed; the database served as the only
source of patient information. The results of each test
ordered were tabulated into summary tables, including
whether each test result was considered normal or
abnormal based on the laboratory’s reference ranges.
The clinical or scientific rationale for each study
was not recorded in the retrospective database as
reasons were too widely distributed and were all part of
normal patient care over the 1-year period but included
injury or illness evaluation and diagnosis, routine
health screening, performance testing, or as part of
multidisciplinary management of chronic conditions.
Communication of the laboratory results and their
clinical relevance was performed as a usual part of
patient care. Owing to the retrospective nature of this
project, no changes in patient management were made
70 D. C. Nabhan et al.

during the one year time period. This study was

approved by the Southern California University of
Health Sciences Institutional Review Board.

Results

Retrospective analysis of data revealed that 539

different laboratory studies were ordered on 137 athletes
over a 1-year period, with an average of about 4 tests
ordered per patient. The patient population who required
laboratory evaluation for their clinic visit consisted of 86
male and 51 female athletes. The most commonly
ordered tests were the CBC, CMP, thyroid stimulating
hormone (TSH), serum ferritin, creatine kinase (CK),
serum iron, and total iron binding capacity (TIBC), total
cortisol, urinalysis, and lipid panels (Fig 1). The resulting
laboratory reported 217 out of the 539 studies as
abnormal (Table 1).

Discussion

Laboratory testing is an important component of the

management of the athletic patient and should be
considered by the clinician working in the sports
medicine setting. Although not all chiropractic offices
have the capability or desire to order and utilize these
laboratory tests, this report describes the importance of
these tests, how the results in the athletic population may
differ from the general public, and the clinical signifi-
cance of test results in this special population.
Laboratory testing of the elite athlete has been
described as a routine part of health screening. 1–7
However, detailed descriptions of the tests commonly
ordered in the population for both diagnostic and
screening purposes, the frequency of abnormal results, Fig 1. List of test ordered between September 2009 and
and the clinical utility of these findings have not been September 2010.
published in detail. Prior investigations have reported
findings of specific screening tests, such as iron comprehensive metabolic panel, total cortisol, creatine
screening, in athletic populations; however, to the kinase, complete blood count, iron panel, and serum
authors’ knowledge, a retrospective study describing ferritin. The studies ordered appear to be unique to the
the practice patterns in regard to types of tests patient population studied, as tests such as creatine
performed in a sports medicine clinic over a time kinase and serum cortisol were ordered more frequently
interval and percentage of abnormal tests has not been in this population then as described in past studies on
performed. This study provides new insight on tests practice patterns of doctors of chiropractic. The results
that are used in the sports medicine setting and suggest the utility of laboratory analysis is increased in
describes the results of this testing. a competitive sports environment to monitor health and
In the population studied, there were a high number performance. Biomarkers may be used to analyze
of abnormal results (40%; 217/539). Tests with high adaptation to training and identify physiological
numbers of abnormal results included the lipid panel, explanations for changes in performance. 10,11 Serum
Laboratory Tests
Table 1 Percentage of Abnormal Laboratory Results Among the 7 Most Common Reported Panels
Test
Lipid panel
Comp metabolic panel with estimated glomerular filtration rate
Cortisol, total
Creatine kinase, total
Complete blood count
Ferritin, serum
Iron and total iron binding capacity, serum
cortisol, serum iron, creatine kinase, and vitamin D are
all studies that may help clinicians and sports scientists
explain changes in performance and assess training
status or may be used to monitor the effectiveness of
nutritional intervention. 1,10,11,13–15
The sports medicine patient population presents
clinical challenges to the interpreting physician when
analyzing athletes’ laboratory results as compared to
normals. 12 A thorough patient history, including recent
training volume, past laboratory values, and a precise
nutrition and hydration assessment may be required to
accurately interpret laboratory data. 11–13 The unique
metabolic demands of elite athletes to excel in elite sport
commonly result in abnormal laboratory findings when
compared to the general population. 1–7,14,15 Reference
laboratory values often do not necessarily reflect what is
normal or abnormal for an elite athlete in training. 16
Review of Commonly Ordered Laboratory Studies
Based on the results of this study, laboratory tests
that may be routinely considered when evaluating an
athlete include the CBC, CMP, serum ferritin, serum
iron and TIBC, TSH, vitamin D, lipid panels, creatine
kinase, serum cortisol, and urinalysis.
CBC With Differential
The CBC is performed to determine a general health
status and to screen for, diagnose, or monitor any one of a
variety of diseases and conditions that affect blood cells,
such as anemia, infection, inflammation, bleeding disor-
ders, or cancer. 17 The hematocrit and platelet count can
sometimes be abnormally high in athletes, particularly if
the athlete is dehydrated. 17 Mean corpuscular volume is a
measurement of the average size of red blood cells (RBC),
mean corpuscular hemoglobin (MCH) is a calculation of
the average amount of oxygen-carrying hemoglobin
inside a red blood cell, MCH concentration is a calculation
of the average percentage of hemoglobin inside a red cell,
red cell distribution width is a calculation of the variation
71
Percentage marked as abnormal
Abnormal Total by the laboratory
11 18 61
46 90 51
18 36 50
26 59 44
48 114 42
26 82 32
15 59 25
in the size of RBC, and a reticulocyte count is a
measurement of the absolute count or percentage of
young RBC in blood. 17 These tests can assist the provider
in determining certain types of anemia and assist with
further work-up.
White blood cell (WBC) counts are important in
assessing for general inflammation or infection. The
WBC count helps diagnose infection or inflammatory
process and may be used to determine the presence of
other diseases that affect WBCs such as allergies, bone
marrow disease, or immune disorders. 17 Highly trained
endurance athletes may have a low WBC count due to
training. 18
Iron Panel
Iron-deficiency anemia is the most common cause of
anemia in athletes and presents with common signs
such as fatigue, headache, joint pain and weakness
which could otherwise be overlooked as a sign of
over-training or dehydration. 7 It is therefore extremely
important to screen for this type of anemia by utilizing a
CBC and assessing the mean corpuscular volume,
MCH, red cell distribution width along with a serum
ferritin, serum iron and TIBC. Serum iron tests are
typically ordered as follow-up tests when abnormal
results are found on routine CBC, such as a decreased
hemoglobin and hematocrit level. They may also be
ordered when iron deficiency or iron overload is
suspected. These secondary tests determine the levels
of free and stored iron in the blood and are useful labs
to determine potential causes of anemia. The TIBC
helps assess the body's ability to transport iron in the
blood and is usually elevated with iron-deficiency
anemia. As the iron level is low in the blood stream, the
TIBC will be increased since transferrin saturation is
very low. 20 TIBC may be ordered along with serum
iron when it appears that an athlete has iron deficiency
or overload. and should be assessed for in all athletes
with similar complaints. 20
72
Comprehensive Metabolic Panel
The CMP includes testing for multiple electrolytes
and metabolites such as sodium, potassium, chloride,
bicarbonate, blood urea nitrogen (BUN), creatinine,
fasting glucose, calcium, magnesium, albumin, aspar-
tate amino transferase (AST), alanine amino transferase
(ALT), alkaline phosphatase, and bilirubin.
Electrolytes such as sodium and potassium are
frequently abnormal in the athlete and are routinely
evaluated in the sports medicine clinic and emergency
department settings. Sodium levels generally help
determine if a disease or condition involving the
brain, lungs, liver, heart, kidney, thyroid, or adrenal
glands is causing or being exacerbated by a sodium
deficiency or excess. Urine sodium levels are typically
tested in athletes who have abnormal blood sodium
levels to help determine whether an imbalance is from,
for example, taking in too much sodium or losing too
much sodium. 17 A high blood sodium level is almost
always due to inadequate water intake and dehydration,
with symptoms including dry mucous membranes,
thirst, agitation, restlessness, acting irrationally, and
coma or convulsions if the sodium level rises to
extremely high concentrations. 17 In the athlete, sodium
levels may be low with excess water intake and may be
high with dehydration. Severely low sodium levels, or
hyponatremia, may produce nausea, cramping, or
neurologic problems and may quickly become a
medical emergency if not addressed properly. This
has been reported in up to 50% of marathon runners
who collapse at the finish line and can be life-
threatening if not managed appropriately. 21 Potassium
is evaluated to assess for hyper or hypokalemia.
Hyperkalemia is often seen in kidney disease, but
many drugs can decrease potassium excretion from the
body and result in this condition. 17 Hypokalemia can
occur if an athlete has diarrhea, vomiting, or extreme
sweating or drinks excessive caffeine and may cause
weakness, cramping, and cardiac rhythm disturbances
that can be fatal. 22
BUN and serum creatinine are primarily used to
evaluate kidney function, muscle breakdown, and to
monitor athletes with acute kidney injury. It also may
be used to evaluate a person's general health status. 17
In regards to the athlete, BUN and serum creatinine
may be elevated due to a condition that results in
decreased blood flow to the kidneys, such as shock,
stress, severe sun burn, or dehydration. 17 In athletes,
creatinine has been shown to be directly related to body
mass index, and this should be considered when
interpreting creatinine levels in larger individuals. 23
D. C. Nabhan et al.
Serum fasting glucose is a screen for diabetes, hyper-
glycemia and hypoglycemia. In the athletic population,
glucose levels may be elevated acutely due to stress and
demands of exercise causing symptoms such as sweating,
hunger, confusion, and anxiety. 17 Exercise-induced
hypoglycemia has been reported in endurance athletes
and, if encountered, should be treated immediately to
prevent complications including seizure and permanent
brain damage. 24
Serum albumin is a non-specific screening that assists
is diagnosis and management of several diseases. 17 In an
athlete low albumin levels can be seen with acute
inflammation, shock or poor nutrition whereas high
albumin levels may be due to dehydration. 17 Addition-
ally, low levels may be seen in conditions where the body
does not properly absorb and digest proteins, such as
Crohn's disease or celiac disease or in which large
volumes of protein are lost from the intestines. 17
Athletes have been shown to have lower albumin levels
than non-athletic control populations. 25
Two key important aspects of the liver panel include
the AST and ALT enzymes, which help to detect liver
injury, with ALT being a more specific marker of liver
damage than AST. AST/ALT are often measured when
signs and symptoms of liver disease are present
including fatigue, weakness, loss of appetite, swelling
or jaundice. In the athlete AST elevation is a routine
finding associated with increased physical exertion and
if found in isolation often does not require additional
work up. 2
Lipid Panel
Lipid panels may also be a routine part of health
screening of the athlete. The basic lipid panel includes
such tests as total cholesterol, which measures all of the
cholesterol in all of the lipoprotein particles, the low-
density lipoprotein, often called “bad cholesterol” because
it deposits excess cholesterol in walls of blood vessels,
high-density lipoprotein, often called “good cholesterol”
because it removes excess cholesterol and carries it to the
liver for removal, and triglycerides, which are measures
of all the triglycerides in all the lipoprotein particles. 17
The high-density lipoprotein is typically high in athletes
and is often abnormally high in well-trained athletes. 26
Careful consideration should be given when prescribing
statins to athletes, as it has been reported that only 20% of
athletes can tolerate their use without muscular side
effects. 27
Vitamin B12
Evaluating athlete’s vitamin B12 levels is com-
monly performed and may lead to supplementation
Laboratory Tests
with intramuscular injection when deficient. Most
athletes who eat a balanced omnivorous diet do not
need to worry about vitamin B12 deficiency, but those on
energy-restrictive diets, those with heavy alcohol use for
more than two weeks, and strict vegetarians should
consider supplementation. 28 An athlete who is deficient
in vitamin B12 may have decreased cognitive function
causing impaired concentration, or compromised aerobic
capacity resulting in decreased athletic performance. 28
Vitamin D
Assessing 25(OH) vitamin D levels may be an
important factor to consider during as part of a routine
screening assessment, particularly in the athlete with
bone injury. Vitamin D levels help determine if bone
weakness, bone malformation, or abnormal metabolism
of calcium (reflected by abnormal calcium, phospho-
rus, and parathyroid hormone) is occurring as a result
of a deficiency or excess of vitamin D. 29 Recent
literature suggests that athletic performance may be
affected by vitamin D as well. 29 Vitamin D has been
shown to increase the size and number of type II fast
twitch muscle fibers and is directly associated with
musculoskeletal performance and the prevention of
bone loss. 30
Thyroid Panel
Thyroid stimulating hormone is an excellent screening
test to determine if chronic athlete fatigue, weakness,
weight loss or gain, depression/anxiety, or sleep distur-
bances interfering with training may be related to thyroid
hormone. 31 If TSH level is abnormal, it should be
followed with a test for total T4 or free T4 for further
investigation on the cause and severity of thyroid
dysfunction. 32
Urinalysis
Urinalysis provides valuable information when work-
ing with the athletic population. Dehydration not only
reduces athletic performance, and places athletes at risk of
health problems. Monitoring hydration has significant
value in maximizing performance during training and
competition. It also offers medical personnel the oppor-
tunity to reduce health risks in situations where athletes
engage in intentional weight loss. Simple non-invasive
techniques, including weight monitoring and urine tests
can provide useful information. 34 In-office dipstick
urinalysis is routinely performed at this medical clinic
for diagnostic, screening and sport science purposes. As a
diagnostic screening, urinalysis may be ordered as a
first line study in the management of urinary tract
infection, abdominal trauma, hematuria, determining
73
hydration status and for a number of internal medical
conditions. An important example of monitoring hydra-
tion with urinalysis is its use in weight class sports such
as boxing, wrestling or judo. Athletes in these types of
sport often are required by sporting rules to have their
hydration status simultaneously evaluated when their
body weights are measured in an attempt to ensure
increased accuracy in determining the athletes correct
weight class. To accomplish this, urine specific gravity is
used as an indicator of hydration status. In this clinic,
digital refractometry is the preferred method to measure
urine specific gravity (Fig 2). Digital refractometry has
previously been described as a safe and accurate
representation of urine specific gravity in athletes. 34
Creatine Kinase and Serum Cortisol
Creatine kinase and serum cortisol are tests that were
routinely ordered in this study but are less frequently
used in the general population. These tests have been
previously described as possible predictors of over-
training. 10,11 In this study, there were a high percentage
of elevated creatine kinase and total cortisol tests, with
50% of total cortisol and 44% of creatine kinase results
identified as being abnormal. In the athletic patient
population the elevation of these specific studies may
not define overtraining but is rather as a sign of acute
muscle breakdown and stress seen with exercise or
heavy training and serves as a small piece of the
diagnosis of overtraining syndromes. 10,11
Cortisol is a glucocorticosteroid produced in the ad-
renal cortex that plays an important role in metabolism of
macronutrients (Fig 3). 11 In normal conditions, cortisol
follows a diurnal pattern of secretion, with elevated levels
in the morning and lower levels in the evening. Adrenal or
pituitary dysfunction and stress can disrupt normal cortisol
Fig 2. A pen refractometer is used to analyze urine specific
gravity, an estimate of hydration status.
74
production. 11 Elevated cortisol can be associated with
increased physical or emotional stress, or with Cushing’s
syndrome. 6,11 In athletes, if Cushing’s syndrome is not
suspected, increases in cortisol are associated with
increased physiological strain. 6
Creatine kinase is an enzyme present in numerous
tissues in the human body. 11 In particular, there are
high levels of creatine kinase in skeletal muscle, the
heart and brain. 11 A CK test measures the breakdown
of this enzyme in the body. 11 Laboratory tests have
been developed for specific isozymes of CK to
differentiate whether a high CK is specifically due to
brain (CPK [creatine phosphokinase]-1), heart (CPK-2)
or skeletal muscle (CPK-3) damage. 11 CK is elevated 1
to 2 days after strenuous physical activity, and remain
elevated for several days. 7 CK is often elevated in
athletes due to normal training, ranging from 7% to
137% higher in athletes than in the general popula-
tion. 5 Monitoring CK in the athletic population may be
a useful tool in evaluation of acute muscle damage in
Fig 3. Functions of cortisol. CAMP, cyclic adenosine monophosphate.
D. C. Nabhan et al.
the athlete, and prevention of injury due to muscle
damage and fatigue. 5 Isolated CK elevation, however, is
not diagnostic of overtraining syndrome and can occur in
numerous other conditions in which training occurs
beyond the body's ability to recover (Table 2). 5
The Use of Laboratory Tests in This Sports Medicine
Clinic Setting
The routine use of laboratory diagnostic studies in
this clinic, as compared to other studies showing DCs
rarely directly order laboratory tests, 36 may be
explained by the collaborative form of multidiscipli-
nary medicine practiced at this facility and the level of
training of the chiropractic physicians. The chiropractic
physician who directs the clinic and the attending
chiropractic physician are both Diplomates of the
American Chiropractic Board of Sports Physicians with
advanced training in Sports Medicine diagnosis and
treatment. In addition to the clinics consulting physi-
Laboratory Tests
Table 2 Creatine Kinase Values Found in Some Muscular
Pathology.
Muscular Pathology CK Value Increases
Duchenne and Becker dystrophies 25-200-fold
Limb-girdle muscular dystrophy 10-100-fold
Facioscapulohumeral dystrophy 3-fold
Distal myopathy 3-fold
Endocrine myopathy Up to 10-fold
Congenital myopathies Slight increase
Metabolic myopathy Slight increase
Mitochondrial myopathy Slight increase
Drug-induced myopathy Slight or no increase
CK, creatine kinase.
Elevations in creatine kinase are a common occurrence in the
training athlete, as well as in several musculoskeletal conditions
listed above. Clinical correlation should be made when
interpreting CK values.
cians, many other outside providers are routinely called
upon for co-management of cases. During the 12-month
period in which this data was collected, medical doctors,
osteopaths, physical therapists, athletic trainers, a
podiatrist, and an optometrist performed clinical rota-
tions in this facility. The high utilization of laboratory
studies in this study may be descriptive of the potential
role of the chiropractic sports physician in multidisci-
plinary sports medicine.
Limitations
The data recorded were a retrospective analysis of
studies ordered by only 1 provider over a time period of 1
year in a unique sports medicine setting. Therefore, the
results cannot necessarily be generalizable to other
locations or practices. Utilization of laboratory diagnos-
tic tests by doctors of chiropractic with sports medicine
certification cannot be assumed to represent general
chiropractic practice. Identification of clinical or scientific
rationale for each laboratory study or panel was not
collected; therefore, this study did not report on the
reasoning behind each test. Future studies comparing
laboratory values in different sports or training programs
(eg, endurance vs power sports, male vs female
performance) would be beneficial in learning more about
sports injury management, prevention and recovery.
Conclusion
This retrospective study describes the variety of tests
ordered for diagnosis and screening of elite athletes by
75
1 doctor of chiropractic in an interdisciplinary sports
medicine clinic over a 1-year period. A high percentage
of the results were flagged as abnormal by the laboratory.
These findings suggest that the unique physiology of the
elite athlete must be considered when interpreting labo-
ratory findings in this population.
Funding Sources and Conflicts of Interest
No funding sources or conflicts of interest were reported
for this study.
References
1. Christensen MG, Kollasch MW, Hyland JK. Practice analysis
of chiropractic 2010. Greeley, CO: National Board of
Chiropractic Examiners; 2010.
2. Coutts AJ, Wallace LK, Slattery KM. Monitoring changes in
performance, physiology, biochemistry, and Fallon KE. Utility
of hematological and iron-related screening in elite athletes.
Clin J Sport Med 2004;14(3):145–52.
3. Fallon KE. The clinical utility of screening of biochemical
parameters in elite athletes: analysis of 100 cases. Br J Sports
Med 2008;42(5):334–7.
4. Fallon KE. Screening for haematological and iron-related
abnormalities in elite athletes–Analysis of 576 cases. J Sci Med
Sport 2008;11(3):329–36.
5. Ljungqvist A, Jenoure P, Engebretsen L, Alonso JM, Bahr R,
Clough A, et al. The International Olympic Committee (IOC)
Consensus Statement on periodic health evaluation of elite
athletes March 2009. Br J Sports Med 2009;43(9):631–43.
6. Urhausen A, Kindermann W. Diagnosis of overtraining: what
tools do we have? Sports Med 2002;32(2):95–102.
7. Brancaccio P, Maffulli N, Buonauro R, Limongelli FM. Serum
enzyme monitoring in sports medicine. Clin Sports Med
2008;27(1):1–18 [vii].
8. Nikolaidis MG, Protosygellou MD, Petridou A, Tsalis G,
Tsigilis N, Mougios V. Hematologic and biochemical profile of
juvenile and adult athletes of both sexes: implications for
clinical evaluation. Int J Sports Med 2003;24(7):506–11.
9. Haldeman S. Principles and practices of chiropractic. 3rd ed.
McGraw-Hill Medical; 2004.
10. Coutts AJ, Wallace LK, Slattery KM. Monitoring changes in
performance, physiology, biochemistry, and psychology during
overreaching and recovery in triathletes. Int J Sports Med
2007;28(2):125–34.
11. Brancaccio P, Maffulli N, Limongelli FM. Creatine kinase
monitoring in sport medicine. Br Med Bull 2007;81-
82:209–30.
12. Fallon KE, Trevitt AC. Optimising a curriculum for clinical
haematology and biochemistry in sports medicine: a Delphi
approach. Br J Sports Med 2006;40(2):139–44.
13. Viru A, Viru M. Cortisol—essential adaptation hormone in
exercise. Int J Sports Med 2004;25(6):461–4.
76
14. Constantini NW, Arieli R, Chodick G, Dubnov-Raz G. High
prevalence of vitamin D insufficiency in athletes and dancers.
Clin J Sport Med 2010;20(5):368–71.
15. Friedmann B, Weller E, Mairbaurl H, Bärtsch P. Effects of iron
repletion on blood volume and performance capacity in young
athletes. Med Sci Sports Exerc 2001;33(5):741–6.
16. Schumacher YO, Schmid A, Grathwohl D, Bültermann D, Berg A.
Hematological indices and iron status in athletes of various sports
and performances. Med Sci Sports Exerc 2002;34(5):869–75.
17. Fischbach FT. A manual of laboratory and diagnostic tests. 7th
ed. Lippincott Williams & Wilkins; 2003.
18. Horn PL, Pyne DB, Hopkins WG, Barnes CJ. Lower white
blood cell counts in elite athletes training for highly aerobic
sports. Eur J Appl Physiol 2010;110(5):925–32.
19. Banfi G, Mauri C, Morelli B, Di Gaetano N, Malgeri U,
Melegati G. Reticulocyte count, mean reticulocyte volume,
immature reticulocyte fraction, and mean sphered cell
volume in elite athletes: reference values and comparison
with the general population. Clin Chem Lab Med 2006;44(5):
616–22.
20. Noakes, Norman RJ, Buck RH, Godlonton J, Stevenson K,
Pittaway D. The incidence of hyponatremia during prolonged
ultraendurance exercise. Med Sci Sports Exerc 1990;22(2):
165–70.
21. Rigato I, Blarasin L, Kette F. Severe hypokalemia in 2 young
bicycle riders due to massive caffeine intake. Clin J Sport Med
2010;20(2):128–30.
22. Banfi G, Fabbro MD. Relation between serum creatinine and
body mass index in elite athletes of different sport disciplines.
Br J Sports Med 2006;40(8):675–8.
D. C. Nabhan et al.
23. Felig P, Cherif A, Minagawa A, Wahren J. Hypoglycemia
during prolonged exercise in normal men. N Engl J Med
1982;306(15):895–900.
24. Lippi G, Brocco G, Franchini M, Schena F, Guidi G.
Comparison of serum creatinine, uric acid, albumin and
glucose in male professional endurance athletes compared
with healthy controls. Clin Chem Lab Med 2005;42(6):644–7.
25. Reamy BV, Thompson PD. Lipid disorders in athletes. Curr
Sports Med Rep 2004;3(2):70–6.
26. Sinzinger H, O’Grady J. Professional athletes suffering from familial
hypercholesterolaemia rarely tolerate statin treatment because of
muscular problems. Br J Clin Pharmacol 2004;57(4):525–8.
27. Lukaski HC. Vitamin and mineral status: effects on physical
performance. Nutrition 2004;20:632–44.
28. Hamilton B. Vitamin D, and human skeletal muscle. Scand J
Med Sci Sports 2010;20(2):182–90.
29. Holick MF. Vitamin D, deficiency. N Engl J Med
2007;357(3):266–81.
30. Reid VL, Gleeson M, Williams N, Clancy RL. Clinical
investigation of athletes with persistent fatigue and/or recurrent
infections. Br J Sports Med 2004;38(1):42–5.
31. Dayan CM. Interpretation of thyroid function tests. Lancet
2001;357(9256):619–24.
32. Oppliger RA, Bartok C. Hydration testing of athletes. Sports
Med 2002;32(15):959–71.
33. Christensen MG, Hyland JK, Goertz CM, Kollasch MW, Shotts
BL, Blumlein NL, et al. Practice analysis of chiropractic 2015: A
project report, survey analysis, and summary of the practice of
chiropractic within the United States. Greeley, CO: National
Board of Chiropractic Examiners; 2015.